CV Flashcards

Question

What is Prinzmetal's Angina?

Answer 1

* aka variant angina * Produced by Coronary vasospasm (rather than occlusion) * Vasospastic angina that occurs at rest. * Triggered by stress, cold weather, smoking, medications, etc * **Presentation:** * **ST elevation during episode on 12-lead** * patients have a higher incidence of migraine HA and Raynaud’s (perhaps due to a basic vaso-spastic disease) * Treatment: Nitrates, CCBs

Answer 2

Things to know: * **The indication for insertion of the pacemaker or ICD** * **Ask why?** * The underlying rhythm and rate * Do you know what number * The type of pacemaker (demand, fixed), the chamber paced, and the chamber sensed * Does your heart ever beat on its own? Or are you completely dependent on it? * **Have the pacemaker or defibrillator interrogated by a qualified member of CIED** * Note current settings and battery life * Evaluate effect of magnet * Inactivate ICD tachyarrhythmia detection and put defibrillator pads on

Answer 3

* **Device should be evaluated before surgery** * **Pacemakers**: Assess w/in **12 mo** of elective sx * **ICD**: assess w/in **6 m**o of elective sx * Ex: Pacemaker evaluation → card that has date of insertion, manufacturer, contact rep * Hospital contacts major company reps in area. Always available and can answer questions. Assist with pre/intra/post op

Answer 4

* Electromagnetic interference can occur with electrocautery, which can inhibit pacemaker firing * Ex: Demand pacemakers sense electrocautery→ inhibit pacemaker firing → ASYSTOLE * **_ICD devices →**_ _**should have tachyarrythmia treatment algorithms program turned off before sx and on after sx_** * **Prevent unwanted shocks that signals might interpret as V tach or V fib** * **ICD always have pacemaker fx → place in asynchronous mode** * **Ensure monitor enabled to displace pacer spikes \*\*** * **Have a magnet immediately available.** * Most pacemakers can be converted to a fixed rate (asynchronous mode) by placing a magnet over the pacemaker box * Demand pacemakers Intraop: * **Program Asynchronous mode** * **Place magnet over device** – converts to fixed rate (90-100 bpm) * Ensure when magnet removal → automatically resets when removed (pacemaker rep helps) * Grounding pads should be as far from the pulse generator and leads as possible * **Bipolar** electrocautery is **preferred**; avoid monopolar * Monitor some form of blood flow (pulse oximetry, intra-arterial BP measurement) * **Have external pacing and crash cart available**

Answer 5

* stature (obese?) * **sternal incision** (scars), pacemaker box * **PMI-5**^th**ICS @ or just medial to left MCL (supine about hte size of quarter)** * **JVD**→ Jugular venous pressure- CRNAs do not perform * Jugular venous pressure provides an estimate of central venous pressure (CVP). * Jugular vein distention is a sign of increased CVP. * Increased CVP: * right-sided heart failure * pulmonary hypertension * tricuspid stenosis * superior vena cava obstruction. * **Edema**

Answer 6

* **PMI (\< 2.5cm) – point of maximal impulse (~size of quarter)** * **Cardiac Apex:** The tapered inferior tip of the left ventricle → **\*\*produces the apical impulse** * Children/Young adults: PMI easy to visualize/palpate * As chest deepens the AP diameter → impulse harder to find * **Normal Location:** * Located 5^th intercostal space, midclavicular line * Supine= the normal PMI about the size of a quarter (~1-2.5 cm). * **Thrills**- vibratory/buzzing sensations caused by underlying turbulent flow * Thrills can be palpated by pressing the ball of the hand firmly on the chest. * The presence of thrill changes the grading of murmurs

Answer 7

**Abnormal PMI locations:** * **Right ventricular Hypertrophy**- shifted to xiphoid or epigastric area * **Ventricular dilation (HF, cardiomyopathy, IHD)-** displaced laterally toward axilla * **Pregnancy-** shift apical impulse upward and left

Answer 8

1. Aortic valve 1. **Right** sternal, **2^nd** intercostal space 2. Pulmonic valve 1. **Left** sternal border, **2^nd** intercostal space 3. Erb’s point- **Left** sternal border, **3rd intercostal** * hear **S1 + S2 sounds equally** (S2 is best auscultated here) 4. Tricuspid valve- fourth (or fifth) intercostal space, left sternal border 5. Mitral valve- 5^th left intercostal mid-clavicular All people enjoy time magazine or **APE T**O **M**AN

Answer 9

* S1 * Closure of mitral and tricuspid valves Marks onset of systole * S2 * Closure of aortic and pulmonic valves * Onset of diastole * S3 (ventricular gallop) * Physiologic in children, young adults, and pregnancy (last trimester). Pathologic in adults \> 40 → heart failure. “Kentucky” * S4 (atrial gallop) * Occ is normal in trained athletes. * Usually suggest ventricular hypertrophy (esp in older adults)- from increased resistance in ventricular filling “Tennessee”

Answer 10

**Physiologic- abnormal sound/murmur result from physiologic changes in body** **Pathologic- abnormal sounds arise from structural abnormalities in heart or great vessels**

Answer 11

* Grade 1 * Very faint, heard only after the listener has “tuned in” * Grade 2 * Quiet, but heard immediately after placing the stethoscope on the chest * Grade 3 * Moderately loud * Grade 4 * Loud with *palpable thrill* * Grade 5 * Very loud, with ***thrill**.* May be heard when the stethoscope is partly off the chest * Grade 6 * Very loud, with ***thrill***. May be heard with stethoscope entirely off chest **Grade 4-6: added presence of palpable thrill** * Ex: Moderately loud murmur in R, 2^nd intercostal space that radiates to the neck→ descriptive of Grade 3 murmur * DOCUMENT: “moderately loud, grade 3/6 murmur in the right 2^nd intercoastal space radiating to the neck”

Answer 12

* aortic stenosis * timing: midsystolic * radiation: often to the carotids (neck) * aortic regurgitation * timing: holodiastolic * radiation: often to the carotids, if loud àto the apex * mitral stenosis * timint: middiastolic * radiation: little or none * mitral regurgitation * timing: holosystolic * radiation: to the left axilla * mitral valve prolapse * timing: midsystolic click * radiation: no radiation, but a ballooning of the mitral valve into left atrium

Answer 13

* Timing allows us to differentiate between systolic and diastolic murmurs. * Systolic murmur: between S1 and S2 * Diastolic murmurs: between S2 and S1

Answer 14

**MRS****.****ASS** **MSD** **-****ARD** MRS= Mitral regurgitation/systolic ASS= Aortic stenosis/systolic MSD= Mitral stenosis/ diastolic ARD= Aortic regurge/diastolic

Answer 15

* HTN = \> 130/80 mmHg (2017 ACC/AHA) * HTN= inc risk for LVH, heart failure, IHD, CKD, CVA, & PAD * **preoperative goals:** * identify secondary causes of HTN: coarctation of the aorta, pheo, hyperthyroidism, OSA, illicit drug use, etc * identify cardiac risk factors (smoking, diabetes, obesity) * assess for end target organ damage (cardiomegaly, bruits, etc) * If target organ end dame exist→ additional testing needed * SBP \> 180 mmHg, DBP \>110 mmHgà delay? * Might be considered * **Without END ORGAN DAMAGE:** Little association w/ elevated BP \> 180/110 with adverse outcomes * Risks vs benefits: if no EOD * Benefit: delaying sx to optimize HTN * Risk: delay procedure * **\>220/120 → Lovern Delays**

Answer 16

* If patient has long-standing severe HTN or uncontrolled HTN * NEED: * 12-lead ECG * Serum Cr/BUN * If on diuretics --\> BMP/CMP * Continue meds morning of sx (except ACEIs and ARBs) * Anti-anxiety medications → for anxiety pt w/ HTN

Answer 17

* 2014 ACC/AHA recommendations: * Continue beta blocker therapy on pts who have been on chronic beta blocker therapy * Discontinuation: may increase perioperative CV morbidity * Start beta blockers on high risk patients * \> 1day prior to surgery; preferably 2-7 days * Harm if started day of surgery **Rule: AntiHTN (minus ACEI and ARBS) → CONTINUE** MEDS TO D/C or CONTINUE → HANDOUT FROM 1^st LECTURE

Answer 18

* Abnormal contractility or abnormal relaxation of the heart muscle * Can be caused by HTN, IHD * Suspected in the presence of orthopnea, nocturnal coughing, fatigue, peripheral edema, 3^rd/4^th heart sound, paroxysmal nocturnal dys, rales, JVD, ascites * **LVH on ECG should raise suspicion** * Decompensated HF/ LV function is high-risk and elective surgery should be **postponed.** * NYHA (NY Heart association) Class 3 or 4 * Medical condition optimized prior to sx

Answer 19

* ECG * CMP, BUN/ CR * BNP (brain naturetic peptide) * \< 100 is normal * CXR, if suspected pulmonary edema * Echo, as objective measure of LV function * Functional status assessment: New York Heart Association * **NYHA Class 1**: no limitation on physical activity * **NYHA Class II:** slight limitation on physical activity * **NYHA Class III:** marked limitation on physical activity * **NYHA Class IV:** inability to do physical activity w/o discomfort-symptoms at rest * HF pts typically based on this scale * **Severe- Decompensated HF/ LV function= Class 3 or 4**

Answer 20

* Identify type of valvular lesion * Presenting w/ Murmurs → Listen to Heart tones * Presenting w/ Valvular abnormalities- attempt to gather old records (can show severity, fx status, recent Echo results) * Evaluate clinical symptoms and testing data * **Greatest risk** if **Severe aortic stenosis** → **valve area is \< 1 cm²** * Symptoms of Aortic stenosis: * Angina * HF * Syncope * Decreased exercise tolerance * Symptoms present → POSTPONE * **_Diastolic murmurs always pathologic and require further evaluation_** * **MSD**= Mitral stenosis/ diastolic * **ARD**= Aortic regurge/diastolic * **If prosthetic heart valve in place:** * May need to bridge anticoagulant therapy * May need SBE (subacute bacterial endocarditis) prophylaxis

Answer 21

* **Greatest risk** if **Severe aortic stenosis** → **valve area is \< 1 cm²** * Symptoms of Aortic stenosis: * Angina * HF * Syncope * Decreased exercise tolerance * Symptoms present → POSTPONE

Answer 22

* Arrythmias present: * **Obtain:** * 12-Lead EKG * Labs levels: Electrolytes and Antiarrhythmic drug levels * SVT and ventricular tachyarrhythmias associated with perioperative risk * LBBB is strongly associated w/ CAD * **If new, stress testing or consultation needed** * **Postpone** surgery if, * uncontrolled atrial fibrillation * ventricular tachycardia * new-onset atrial fibrillation * symptomatic bradycardia * high-grade or third degree HB

Answer 23

* Need to ask about anticoagulants and antiplatelet medications * Decision to D/C meds based on interdisciplinary team * **Most common guidelines:** * **Antiplatelet** (ASA, Plavix, Brilinta, Effient) * Discontinue 7-10 days prior surgery * **Anticoagulants** (Coumadin, LMWH) * Discontinue 3-5 days (Coumadin) * INR \<1.5 * Discontinue 12 hours prior (LMWH) * **Fibrinolytic drugs** (TPA,Streptokinase, Urokinase) * Usually cannot discontinue

Answer 24

* Not specific for Ischemic Heart Disease * **Useful for:** * cardiomegaly * pulmonary vascular congestion/ pulmonary edema (CHF) * pleural effusions * tumors * suspected mediastinal masses * REVIEW CXR SLIDES FOR ORAL EXAM

Answer 25

1. ST segment elevation , ≥1mm 2. T wave inversion 3. Development of Q waves → myocardial necrosis 4. ST segment depression, flat or downslope of ≥1mm 5. T wave “pseudonormalization” * Patients with chronically inverted T waves (resulting from previous MI) → manifest a return of the T waves to the normal upright position during myocardial ischemia (pseudonormalization of the T wave). * EKG displays ischemia by means of changes in the rate of repolarization of ischemic myocardial tissue. * “Thus, the ST segment and the T wave portions of the ECG signal are primarily affected. Generally, the T wave is affected initially, followed by ST segment changes as ischemia worsens **Know these indicators**

Answer 26

To ascertain general medical condition related to comorbidities and medications * K+ * BUN/ Cr * ABG’s * **Hbg/ Hct** * all CAD pts: CBC → evaluate for anemia. * Calculating ABL w/ CAD → use a higher Hbg/Hct. * **(Hct \< 28 % --\>** **inc periop ischemia)** * INR/ PT * **C-reactive protein-** serum inflammation marker * Atherlosclerosis – Inflammatory process (inflam cells) * Inflammation important in cascade of events → lead to plaque rupture * Ex: Serum inflammation markers **(CRP): INCREASED in susceptible CAD pts**

Answer 27

* EKG Stress Test → traditional method of evaluating pts w/ suspected CAD * Cost effective and least invasive method to detect ischemia * Simulates sympathetic nervous system stimulation by increasing BP and HR and therefore increasing myocardial O2 demand and consumption w/ exercise * Look for ischemia by ECG changes * Positive test: indicated pt at risk for ischemia associated with increased HR * Greatest risk: positive test (ischemia) with MILD exercise. Interpreted based on: * a) Duration of exercise the patient can perform—desire \>3-5 minutes * b) Max. HR achieved—desire HR \> 120bpm * c) Time of onset of ST depression * d) Degree of ST depression * e) Time until resolution of the ST segment

Answer 28

**_ECG criteria_** * ST-segment depression \> 0.2mm (w/in 1^st 3 min) * **The greater the degree depression →** **** **likelihood significant CAD** * **ST seg abnormal w/ Angina in early stages of exercise and persists for several minutes → SEVERE CAD** * ST-elevation \>1.0 mm * Serious ventricular arrhythmias * Development unusual S/S: **angina, breathlessness, cold sweats, pallor, cyanosis** **_Non-ECG responses_** * Failure of SBP to rise * Progressive fall in SBP * Elevation of DBP

Answer 29

* Useful in patients unable to exercise or have contraindications to exercise * CI for exercise ex: PVD with claudication, SC injury, morbid obesity * **Myocardial Perfusion Scans:** * Attempt to dx IHD and allow differentiation of ischemia and infarction * Myocardium imaged at rest and during stress * These tests reveal myocardial wall defects and heart pump performance during increased O₂demand * **Nuclear Tracers (Thallium- IV injection of gamma-emitting radiopharmaceutical)** * Detected over myocardium by specialized scanners → permits the imaging of blood within the heart and lungs. * The area of decreased perfusion (cold spot) during stress indicates ischemia * Ex: A significant coronary obstruction causes less blood flow and thus less tracer activity (cold spot). * **Medications used to induce stress**: adenosine, dipyridamole (Persantine), dobutamine, atropine * Produces rapid HR to create cardiac stress * Normal Arteries: dilate normal coronary arteries, * **Sclerosed Arteries**: evoke minimal or no change to dilation * Look for ischemia by perfusion imaging, not ECG changes * After cardiac stress induced by med→ nuclear scanning performed to asses myocardial perfusion

Answer 30

* **Active cardiac condition** → **(ANY ACTIVE CONDITION= STRESS TESTING)** * unstable coronary syndromes * unstable or severe angina * recent MI * decompensated HF * significant arrhythmias * severe valvular disease * **3 or more clinical risk factors and poor functional capacity having vascular surgery** * Maybe if: * at least 1-2 clinical risk factors and poor functional capacity having intermediate risk surgery if it will change management * at least 1-2 clinical risk factors and good functional capacity having vascular surgery

Answer 31

* Echocardiography is a noninvasive technique for examining the heart and can provide information about its position and size,movements of the valves and chamber, and velocity of blood flow. * Echoes from pulsed high-frequency sound waves are used to locate and study the movements and dimensions of cardiac structures. * **Diagnostic usefulness of ECHO:** * Measurement of the dimensions of cardiac chambers and vessels and the thickness of the myocardium * Global ventricular systolic function: EF * Regional wall motion abnormalities * Valve structure and motion * Can detect blood flow and measure gradients * Chamber enlargement * Detection of pericardial fluid * 2014 AHA/ACC guidelines: **preop ECHO for MODERATE or SERVE valvular abnormalities with no ECHO w/in 1 yr**

Answer 32

**When to Order a Preop Echo** **(when not followed by specialist and don’t know)** * **Current or prior heart failure** * with worsening dyspnea or other change in clinical status * Reassessment of LV function with documented previous LV dysfunction, if not assessed in last year * **Dyspnea** of unknown origin * **Valvular disease** **clinically suspected** * Significant change in symptoms

Answer 33

* Provides the BEST information about the condition of coronary arteries/anatomy * **_Gold standard test for pts undergoing cardiac surgery_** * **Indications:** * pt surviving sudden cardiac death * those considered for CABG * those needing definitive diagnosis for CAD (airline pilots) * **Usefulness:** * diagnose nonatherosclerotic CAD * CA spasm * Kawasaki’s ds * radiation-induced vasculopathy * **Cons:** * Cannot predict which areas of plaque are most likely to rupture and produce acute coronary syndrome * expensive * **2014 ACC/AHA guidelines: do NOT recommend routine preop coronary angiography prior to noncardiac sugery without specific clinical indications**

Answer 34

* Detects atherosclerotic calcifications in CA (vessels that contain calcium) * electron beam CT detects calcifications * **** **“**calcium score” = **** degree of CAD * Test: * Highly sensitive * Low specificity → **(many false positives)** * use is not recommended- results are minimum value

Answer 35

**Delay of elective noncardiac Surgery: (after _____ sx = wait ____ days to get elective sx)** * BALLOON ANGIOPLASTY – wait 14 days * BARE-METAL STENT – wait 30 days * DRUG-ELUTING STENT – wait 12 months (might be considered after 6 mo)

Answer 36

**Current recommendations for dual antiplatelet (ticlopidine or clopidogrel + ASA) therapy**: * Continue for @ least 2 weeks after balloon angioplasty, * for at least 6 weeks after bare metal stent placement, and * for at least 1 year after drug-eluting stent placement

Answer 37

* Guidelines updated in 2017 * Prophylaxis for patients with high risk cardiac conditions associated with high risk of adverse outcomes for infective endocarditis: * Prosthetic heart valves * History of infective endocarditis * Congenital heart disease * Unrepaired cyanotic congenital heart disease * Repaired congenital heart defect with prosthetic material or device, during the 1^st 6 months after the procedure * Repaired congenital heart disease with residual defects * Damaged heart valves * Cardiac transplantation recipients with cardiac valvular disease * Hypertrophic cardiomyopathy

Answer 38

For patients with high cardiac risk, antibiotic prophylaxis is recommended for these procedures/surgeries: * All dental/oral procedures that involve manipulation for gingival tissue, perforation of oral mucosa, or the periapical region of teeth * Invasive respiratory tract procedures with perforation of respiratory mucosa (tonsillectomy, adenoids, abscess drainage, lung biopsy) * Procedures involving _infection_ of GI/GU tract, skin/ musculoskeletal tissue * NOT recommended in routine genitourinary or gastrointestinal tract surgery or bronchoscopy\* * Hepatobiliary procedures w/ high risk of bacteremia * For Cardiac Surgery

Answer 39

All antimicrobial prophylaxis are administered **as a single dose, given 30-60 min**. before procedure (up to 2 hrs after if missed pre-procedure dose) * Standard prophylaxis * Ampicillin 2 gm IV * (50mg/kg pediatrics) * Cefazolin 1 gm IV * (50 mg/kg pediatrics) * Ceftriaxone 1 gm IV * (50 mg/kg pediatrics) * PCN allergic: Clindamycin 600 mg IV * (20 mg/kg pediatrics)

CV Flashcards

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